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NHS England has highlighted the risk of severe distress or death from inappropriate use of naloxone.

In a Patient Safety Alert issued last month, NHS England reminded healthcare professionals that naloxone, which is an opioid/opiate antagonist, could cause potentially fatal acute withdrawal syndrome if administered inappropriately to patients receiving long-term opioid or opiate treatment.

The warning follows three patient safety incidents, two of which were fatal, recorded via the National Learning and Reporting System, where naloxone was used contrary to guidelines in the British National Formulary (BNF). However, because the risk is poorly recognised, NHS England is concerned that cases may be under-reported.

The safety alert recommends that all NHS care organisations using naloxone determine if incidents involving inappropriate use of the drug could occur and consider what action they could take to prevent them.